Survey Finds Troubling Lack of Teamwork in the OR

BY BETSY BATES

SAN FRANCISCO -- Surgeons view collaboration, communication, and teamwork in their operating rooms in sharp contrast to the perspective of nurses and technicians working alongside them, according to survey results presented by Dr. Martin Makary at the annual clinical congress of the American College of Surgeons.

"We think we're doing a great job." But the nurses, anesthesiologists, and technicians "see some problems that we don't see," said Dr. Makary, who serves on the faculty of the departments of surgery and public health at Johns Hopkins University in Baltimore.

Dr. Makary surveyed 2,135 surgical team members, including surgeons, anesthesiologists, certified registered nurse-anesthetists, scrub nurses, and technicians, about social dynamics in the operating room that have been proven to affect surgical outcomes. Surgical team members surveyed worked in 60 hospitals across 16 states, said Dr. Makary, who also represents the surgery department in the university's center for innovation in quality patient care.

Surgeons rated the quality of their colleagues' collaboration and communication skills in the operating room (OR) much higher than their colleagues rated them. On a 100-point scale, surgeons rated fellow surgeons at 85, anesthesiologists at 84, and nurses at 87. Nurses rated surgeons at 48, and anesthesiologists rated surgeons at 70.

Furthermore, Dr. Makary found significant discrepancies among surgeons, anesthesiologists, and others in the OR in how they responded to statements such as "I have the support I need from other personnel in caring for patients," "It is easy to ask questions," and "We work well together as a coordinated team." Surgeons generally thought all was well, while other team members disagreed.

"This is a topic that speaks to the issue of a nurse in the OR knowing that a sponge is retained in the abdomen but not saying anything because of the hierarchy that we have espoused" throughout the history of our profession, Dr. Makary said. "It speaks to the nurse in the OR realizing that a patient is receiving an organ with the wrong blood type but not saying anything because the last time she did she was criticized." The stakes are high, he emphasized.

A study by the Joint Commission on Accreditation of Healthcare Organizations found that communication was the root cause of more than 60% of "sentinel events" in hospitals, Dr. Makary said. For example, almost 80% of wrong-site surgeries are traceable to communication failures, he noted.

The discussant for Dr. Makary's paper, Dr. Edward J. Dunn, said the commission's study contained a "pretty serious message ... about the communication disconnect in operating rooms." A cardiothoracic surgeon who now works with the Veterans Affairs national center for public safety, Dr. Dunn said a first step in making improvements is for surgeons to realize how others feel. If nurses don't feel respected, don't believe they have the power to speak up, and don't feel their input is valued, then they don't believe they're members of a team and won't participate as such, he said. After a study of 7,000 adverse incidents in the VA revealed that 78% were due to failed communication, the VA decided to take communication seriously.

The VA has been closing ORs for 1 day to conduct a peer-to-peer team training program in which colleagues interactively discuss nine filmed clinical vignettes that depict various barriers to collaboration and communication. The training is being administered in operating rooms throughout much of the VA system. Studies of the effectiveness of the training program are ongoing, but they seem to indicate that establishing rules of conduct and talking as a team are central elements for improved communication, Dr. Dunn said.

"All operating teams should consider a 360-degree review of all team members by everyone on the team, including input to the surgeon from everyone in the room," said Dr. John (Jeb) W. Hallett, medical director, Roper St. Francis Heart and Vascular Services, Charleston, S.C., when asked to comment.

"Structured training programs in communication for all OR members are ideal. However, in some situation, surgeons with disordered behavior or anger management problems need to be pulled from the OR by the chief of surgery and sent for professional help. That's the tough part of being chairman," he added.